Transcripts For CSPAN Dangerous Disease Investigators 20140817

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Let us know what you think about the programs youre watching. Call us at the number on your screen. Or email us. Join the conversation. Like us on facebook. Follow us on twitter. Coming up next, a look at how the centers for Disease Control tracks invites highly Infectious Diseases. After that, Healthcare Professionals talk about their experiences fighting diseases in developing countries. At 7 a. M. Eastern, washington journal. Like with your phone calls in the days latest news. With your phone calls and the days latest news. Organizationlth issued a warning recently about ebola, saying that the reported number of cases vastly under estimates the magnitude. We will hear from some of the people who track these highly Infectious Diseases. Officials with the center for Disease Control called disease detectives. This is one hour. Good evening. My name is robin hogan and i am the Vice President of communications for the Robert Wood Johnson foundation. We are very proud to be the sponsor of spotlight health. Welcoming you to tonight presentation. Everyone likes a good epidemic because this is a soldout session. It has been a long day, started at 8 00 this morning in a tent across town. It will end at 8 30 p. M. Tonight. I commend you for your stamina. 12 hours of learning. It has been a fabulous first day. We are really delighted. Thank you. My job is simple tonight. To introduce the panel and inspire you with their brilliance. We have two mds and a dbm tonight to talk to you about epidemiology. First to my left, dr. Neil vorra. He has distinguished himself as a physician. He is a newly discovered virus infecting humans and cattle in the republic of georgia. And human rabies cases associated with organ transplantations. You will be hearing from neil on those stories and others im sure. To the far left is jennifer mcquiston. Jennifer is a dbm by training. She has investigated some exotic tests associated with monkeypox outbreaks. And served more somberly in 9 11, part of the cdc advance team to monitor possible bioterrorism. Flanking these officers is their boss. Tom is the director of the cdc and we are honored to have him with us tonight. I come from new york, sort of the capital of new england. I think of tom not so much as the director of the cdc but the commissioner of health where he was heroic working with mayor bloomberg in almost eliminating smoking in that city if you can believe it. He also drove down and almost eliminated trans fat in their diet of most new york residents. And eliminated Cancer Screening disparities among his many distinctions. He is here as director of the cdc and will moderate the panel. They will moderate the panel, asking questions of his colleagues for about 35 minutes and then we will open it up to you to ask them questions and he will field those from his chair. We will have about 25 minutes of questions and at 8 30 p. M. We will a you go. [applause] i hope you enjoy aspen during the next hour as well. We will tell you what it is like to be a disease detectives. For those of you that saw the movie contagion. Kate winslet is a disease detectives and it is pretty realistic. It is a boots on the ground experience of what the cdc does to keep all of us safe. Eis officers, the program is more than 60 years old and is a really unique type of training. It is the Epidemic Intelligence Services and a clever fellow figured that if he could highlight that we needed this kind of specialist to protect ourselves from biological warfare, he would probably get funding from congress for it. And they would both protect us from biological warfare and from lots of other health threats. That is what it has done for more than 60 years. Victim and of Health Problems are things that officers can potentially investigate. I was assigned to new york city. And as often or maybe usually happens, the person that ring the alarm bell and called the Health Department was an alert clinician. In this case, they called us and said i think i am seeing a lot more drugresistant tuberculosis. And that call basically took 10 years to answer. Because first we had to figure out what was going on in new york city and we found that, in fact, we had a lot way more than had been anticipated. It was largely spreading in hospitals. Patients and healthcare workers were getting infected, coming down with tb, going to hospitals, sometimes dying and maybe making other patients sick. We were able to track the epidemic and we were able to apply the tools to control it. By shedding a light on it, we galvanized action and changed medical treatment. We also identified were the lapses were and where the lesions were. What was going wrong in our hospitals. So we had to call team after team of eis officers as there were outbreaks in the intensive care unit, outbreaks in Public Hospitals and private hospitals and in the jail system. We began to figure out what was going on and very rapidly we figured out what the answer was. The answer was that it was spreading and we could stop it. Even drug resistant tuberculosis we can stop the spread by treating it and isolating patients if needed. It allowed us to rapidly reduce drugresistant tuberculosis. Within the manuscript off to new england journal of medicine asking them to publish this rapid control after a decade of increasing with basic good management. The new england journal wrote back and said we are not sure its a real trend. Wait another year. It came down another 15 , a dramatic decline. But before we print it, how is it going the First Quarter of this year . One of the really rewarding things about solving the mystery is not just the intellectual rewards of solving it, but the human rewards of the Health Benefit that comes from it. After that experience i went over to india where we helped the government implement a program that has resulted in millions of patients treated and millions of lives saved using this same system of establishing effective programs and identify them when they come first. Lets just go to each of the officers and hear a bit about what they are doing. We will start with rabies. A bad disease. Much of my work is focused on rabies which is caused by a virus and is typically transmitted to the bite of an infected animal. Virtually every person that gets rabies will unfortunately died. Last year in maryland, a patient developed rabies and i led the investigation to figure out how it had become exposed. This patient did not have any of the typical risk factors we associate with rabies but he did have a history of kidney transplantation 18 months before his symptoms started. It got us thinking that maybe he had somehow been exposed to rabies through his organ transplantation. It is a life saving intervention for a range of diseases but infections can actually be transmitted from organ donors to organ recipients and that is what we thought might have happened here. Abd organ donor had died of rabies that no one recognized 18 months before. It became our job to figure out going back in time whether or not the donor really had died of rabies. As you can imagine, its not easy going back that far in time. But we were able to locate samples belonging to that donor that had been in the freezer for the last 18 months. And within hours of receiving them, we generated definitive results showing that the organ donor had died of rabies. We proved the transmission had encouraged transplantation but the job was not over. Three other people received organs from the same donor and they were still alive. We were racing against time because they had organs inside of their body. We immediately vaccinated these people and still to this day, they remain alive which is an unprecedented situation. One point to the investigation highlights is the link between animal and human health. We found out that the donor was an avid hunter and had been bitten by reckons multiple times. Raccoons multiple times. Another is bats. They can also carry rabies and other diseases like ebola. In this type of work actually took me to nigeria last year where every year there is a bat festival that takes place where people capture live bats from this cave and they are prepared as food. Our concern was in the course of this festivity, people might be getting exposed to deadly viruses. You might wonder why the cdc would take an interest in an activity on the other side of the planet. Keep in mind that we live in an interconnected world. And so by remaining vigilant, we can better prepare ourselves for the next outbreak. Animals are often the source of human outbreaks. Thats are a particularly problematic species because they are mammals. The things that affect them might infect us and they live in huge colonies. Diseases in the community can perpetuate themselves for long periods of time. I was in a cave in africa called python cave. I saw the python and it is enormous. They did research to figure out how it is an ebola like virus that cause bleeding and death, he had killed one person and nearly killed another and had localized it. Manhattan research to capture bats, release them, figure out what portion carried the virus. Margie scared . Werent you scared . The bats did not scare us because we were wearing protective equipment and the python did not scare us but the cobras scared us. Underneath our protective gear, we wore leather chaps. One of the reasons researchers do investigate animals is the emerging diseases in people often traced back to animals. One situation was in 2003. The first hint that something had gone terribly wrong, this was a threeyearold girl that lived in wisconsin and she developed these very odd and very disturbing skin lesions. I am too young to have been vaccinated for smallpox. There are many researchers who dedicated their Early Careers to eradicating this disease from the world. They took one look at this picture and said, thats smallpox. We were worried when a second case was reported just a few days later from another part of wisconsin. These patients did not know each other. One is a threeyearold girl, one is a businessman. They had both been bitten by six pet prairie dogs. Who here has a prairie dog . Not a good idea. It is a very odd history. These are two diseases that we know prairie dogs can carry but these lesions look like smallpox. They sent the samples to the cdc and while we were waiting for them to be tested, more cases started to be reported. It was clear we had some sort of dramatic out rake happening. I remember waiting for the results to come in and we were saying, please dont be smallpox. We were relieved to be told it was monkeypox. It is only known to occur in africa. Never been reported in north america and certainly not in a north american mammal species. We had no idea how it got here. As a veterinarian im privileged to get to work on a lot of things for the cdc but i was asked to leave the animal lead the animal tracing investigation to figure out what we would do about it. The first step is to interview cases and by now we had 70 human cases associated with this outbreak and everyone had a pet prairie dogs. They came from a dealer outside chicago, illinois. He was literally running a pet dealership out of his garage. We actually sent a team of there to investigate and he not only sold prairie dogs, he also sold african rodents. At some point they had mixed and they had gone on to infect all those people. The pet industry is not very wellregulated. You have to go by wordofmouth and you have to traced back through multiple intermediate dealers where these animals have come from. We finally located a shipment of rodents that had come in from the pet industry six weeks before. The problem was, there were 800 animals in the shipment. When we started tracing out where they had gone, many of them tested positive for monkeypox. We had to presume the entire shipment was infected. It was a very long investigation. We identified a real problem being able to import rodents from africa for the pet trade. Cdc enacted emergency legislation during this outbreak banning the implementation of rodents from africa. It stopped the outbreak and kept it from happening again. We have to worry about the illegal pet trade. They dont raise them in nice, clean facilities. Whatever diseases they are harboring can come over and be in a childs bedroom before we know it. We remain worried about it, we remain vigilant. Did you activate the Emergency Operation center . It was activated for the entire response. Like this is an incredibly important capacity for us to have, some of you may remember the fungal meningitis cases from a year or two ago with contaminated steroid injections, thousands of patients exposed, many that became ill. Working with 23 state Health Departments, we had to notify 13,000 patients within a few weeks. That ability to mobilize rapidly was so important but it is not common enough around the world. We help other countries develop this kind of disease and the Emergency Operation capacity because if they can find a problem sooner, it is better for them and better for us. Monkeypox is just one member of this group of viruses which also includes smallpox. It was eradicated in the late 1970s and we have stopped regularly vaccinating people against smallpox. It actually protects against more than just smallpox. It protects against other viruses such as monkeypox. One of the questions we are interested in, people no longer have the protection that they want got once got. ; i will take you to the country of georgia formally part of the soviet union. Last year, we were contacted by our georgian colleagues. They had a Mysterious Illness characterized by fever and these skin lesions filled with pus. Testing showed that both of these men were actually infected with a never before seen virus closely related to smallpox. I led the investigation that went out in georgia so we can learn more about this virus and one of our concerns is that the cases were already heard about were the tip of the iceberg and maybe more people were actually infected back in georgia. The team i lead was composed of a diverse array of people including veterinarians, epidemiologists. We had a broad array of experts so we can take a conference of approach to this investigation. And we found that people in the region had a history of exposure. Though the exact circumstances behind their exposure remain unclear. The other thing we found is that we suspected this virus probably originated from animals and indeed we found evidence that it circulates among jordan georgian rodents. For me, one of the most amazing aspects of this investigation is that we heard about these two patients in rural georgia all the way in atlanta georgia. Thousands of miles away and we still had it brought to our attention. It speaks to the work that the cdc does with Building Local capacity for Public Health which is part of our Overall Global Health security strategy. Some of you might also be wondering why we spend time studying obscure viruses like this. And particularly for a virus like this, it has the potential to mutate into a more deadly virus like smallpox is believed to have done many years ago. Smallpox is a potential agent of bioterrorism. By understanding this virus and others, we can better prepare ourselves for these types of threats. Some of our partnerships around the world the cdc is pretty well known for what we do in this country. They end up being the most trusted agency and the u. S. Government. But not too many people know what we do around the world. The work that cdc does is better known outside the u. S. And inside. We have staff in 60 countries, 2000 staff working on a wide range of issues and i think one of the most exciting ones is building the capacity to do this type of investigation and response all over the world. The u. S. Ambassador to africa said to me that the cdc is like 911 for the world. Thats great. Really what we like is to make sure that every single country has its own Public Health 911. They mentioned bioterrorism as the underpinnings of why we do some of the work we do. I will talk to you a little bit about 9 11 today. Most of our lives were changed forever. I remember standing in the cdc lobby and the guards put it up on the television screen. I know all of america was so devastated by this. Unlike most americans, i was pulled into action that day. I was able to feel like i was doing something because i was pulled on the plane that flew into manhattan that night. This is not a story that we necessarily talk about a lot but the cdc was the only plain allowed in the sky that day. It was thought to be so important to get Public Health people on the ground working with the new york city Health Department is infrastructure had been damaged, their offices were very close to the World Trade Center. And making sure they get surveillance started. And we were a team of four people initially. We liaison with the Health Department and we came up with a plan. So we put 40 officers in the belly of an air force cargo plane and flew them to new york city several days after the event. We made sure that every person i came to the emergency room was checked out in some way. We were looking for signs and symptoms adjusted for bioterrorism. We also ended up with surveillance associated with recovery efforts. We were able to implement Public Health beyond bioterrorism. By the end of those six weeks, the first anthrax letters that have been mailed to the u. S. Postal system and started to be reported. All those officers got called back to atlanta to begin working on the next outbreak investigation and i think it really characterizes what eis is all about. Youre never still from very long. Youre always moving from one outbreak to the next. The World Trade Center response illustrates that we have a group of people ready to respond at any moment at any time and we can mobilize 40 people to go work on an emergency. I think that is the real value. Is both broad and deep, 15 thousand staff including some of the worlds experts in just about every condition imaginable. One of the things were very proud of in terms of the work the cdc did, now the world is really at the cusp of polio eradication. The Polio Program is so important and so challenging. This is a Polio Vaccination Program in nigeria. There are currently two countries in the world that still have polio thats never going away. Every polio virus is either in nigeria or in pakistan. We can study their whole genome and figure out which is which. Nigeria has made tremendous progress in the past 18 months. Part of the reason is a great coalition, the state government, the gates foundation. World health organization. We have created programs like it and other countries. And the program in nigeria started about five years ago and were started by a graduate of the canyon programs. It is a great example of self learning. That program is getting the best and brightest and i met with them a couple years ago. You all know people that talk about smallpox eradication because it was the most meaningful moment of their career and they are proud of it. Polio will be your smallpox. We turned loose the class and we tripled the class size. Go work on polio. They ultimately went to more than 100 communities. Every month they would go into a specific investigation control measure, come back a month later, and within a few months, they had dramatically improved vaccination rates. It was one of many Different Things it had been used so far this year. We only had four polio cases in nigeria. There are lots of problems and challenges with polio eradication. Weve had violence in pakistan and nigeria. Outbreaks in cameroon. We just had a positive specimen from brazil from the sewage system that matches gina typically with a tutorial ginny polio. Some one came over in advance of the world cup, deposited Something Else in brazil. We have outbreaks in syria, positive outbreaks in israel. The dont want you to begin taking it so blessed. When we began this work in 1988, there were 350,000 polio cases each year. And now we are really on the cusp of eradication. I think we have a reasonable chance getting rid of polio from africa and it will only be the pakistan polio virus that we need to deal with. And i think we can get over the finish line. Eradication is so exciting and has been a goal because it is the ultimate in sustainability and equity because it is forever and for everyone. That is what smallpox eradication has brought. That is what polio eradication will bring. Tremendous progress in so many different areas but i want to ask you each a question or two and we will open it up to the audience. What are some of the most important takehome lessons you have gotten from the outbreak investigations you have done . How do you respect local expertise and be the outside expert . I think along these are the investigations i described, we always work alongside our colleagues in those countries. Particularly the eis programs. Even in nigeria, some of those officers took a break from polio and actually worked with us. It is not so often a case i am learning from them as vice versa because they bring so much to the table with their understanding of the cultural circumstances and local epidemiology. I found it really inspiring. You also develop a type of very healthy respect for how dangerous some of these diseases are. We talk about ebola or rabies, and in addition to that, there are others in this case. It really opens your mind to the challenges that we face around the world. The leading cause of death and americans traveling outside of the u. S. , one of these training programs, one of the officers by hand analyzed more than 10,000 traffic incidents and came up with an analysis of some of the causes of fatalities and his work led to the enactment of seatbelt laws and drunk driving laws and associated with the decline in Motor Vehicle fatalities. What youre developing is a capacity. The ability of countries to collect, analyze, interpret, and use their own data to improve their own health. One of the challenges, of course, if youre working internationally, you dont always speak the language or understand the culture. What we do sometimes transcends politics. Many times we have the opportunity to work in countries where maybe americans arent always welcome but because we are there in the Health Capacity we are. I was try to keep in mind that i am there as an ambassador in many ways. That the impression i leave will have longterm ramifications, either positive or negative. I think on an outbreak investigation, the thing i will always try to keep in the back of my head going into it is to never presume you know what the cause is. Never presume that you know what you will find when you get there. Let the data and investigation carry you to the conclusion. There is an expanding outbreak of a disease called Rocky Mountain fever. It is a tickborne disease, something that had never occurred in arizona before. It is not really a climate hospitable to text. But we begin to get cases and American Indians in the early part of 2000. We sent an officer out and we really thought what she was going to find is the range of that kick would have expanded southward to colorado down into arizona. When we got there, no matter how hard we looked, we couldnt find that kick. We found a completely different tick. It acted totally differently. It was a lesson to me that i thought i knew. We had to trust our instincts. I will ask one more question and open up to the audience. How about your own personal safety . For me, the biggest concern is the traffic. You drive these long distances and you hope that someone doesnt fall asleep at the wheel. We were traveling in these bulletproof vehicles with armed guards. When we get inside the bat cave, i love animals so i was in heaven. The whole floor is literally alive with vermin. You dont know if it is condensation or bat urine to be frank. When dealing with these animals, you have to have that healthy respect. You always have to realize that you are dealing with unknowns. You have to be careful for yourself and others. Other peoples safety youre responsible for. I wanted to continue to care for patients individually. So i arranged to see patients in the tuberculosis clinic, unrelated to the fact that i ended up working on tuberculosis for many years. During my work in that clinic, i became infected with tuberculosis bacteria. I did not get sick with it. You can be either infected or sec and i will probably have that affection other rest of my life with no adverse effects. But no good. Should not have happened. They were getting patients to cough into a cup. All of the infectious particles were coming out of that room. I sent my boss here today a note saying that you have to get the induction rooms fixed. It doesnt take much. All you have to do is put an exhaust pan in. It kills the tuberculosis bacteria so we were able to do that in days. Www. Cspan. Org www. Cspan. Org one thing you can do is analyze what might have happened or what could happen and use that to make everyone safer. I am a woman and i travel sometimes internationally by myself. For my personal safety i am always aware of what the situation on the ground is and making smart decisions about how to protect yourself. I always make sure i locked the hotel room and always make sure that i am in my room my 7 00 or 8 00 at night. I do that in the United States as well, i guess. Its hard to predict what your personal safety on the ground will be. I never worried i was going to catch the disease. We know more about how to protect yourself and we get thousands of vaccinations before we travel internationally sometimes. For me it is more the uncertainty on the ground. My mother was crying on the phone saying, dont go. I think that is what differentiates. We go even when we dont know. You have your bag packed at all times and if you are not on a flight by sundown, someone else will be. That officer is all raise ready to go. We have one here and one here. We heard in the last hour about a recent law enacted in nigeria making it unlawful to treat homosexuals with hiv. You will have some sort of serious relationships with the Nigerian Government and i am wondering if this is something on which the cdc has a position or has made any effort to ameliorate. Cdc provides half of the treatment in the global aids program. We have seen antihomosexuality legislation in uganda, nigeria, and elsewhere. And we are very concerned about it from both the human rights perspective and a Disease Control perspective. If people arent comfortable coming forward, they will be more ill and spread infection more. These issues have gotten very politicized in some of the countries. What we are hoping is to gradually move it back to a right based at roche, a carebased approach so we are providing services to individuals. It has real implications for us. In some of our programs, we no longer record the risk factors people have that have resulted in the hiv infection because it could result in negative consequences. We want to figure out a way that we can get to services that people need and also work diplomatically to the state department to try to get these laws changed. Sometimes the worst way to do this is for americans to say they should change them. It is important to figure out the most effective way to get change to occur within countries. In the early part of the 20th century, we had quarantines of people with tuberculosis. I dont know of other instances where that power had to be exercised. Can you please sketch a scenario where quarantines could be necessary on a broad basis and indicate what Police Powers there are that we can enforce such a state of affairs . Quarantines is a separation of Healthy People in case they have become ill. Isolation is the separation of sick people so they dont make other people infected. Both of those considerations come into play. I will mention tuberculosis, mers and sars. In tuberculosis, we have people that have tb and refuse to take medications and are endangering others. Philosophically, we say your right to swing your fist. Your right to swing your fist ends at my nose. And your right to not take your medicine does not extend to developing a drugresistant form that you cough into my face. New york city was at the epicenter of the outbreak where i helped document as an eis officer. And we rewrote the law because the law had been written in 1959 and there wasnt much in terms of safeguarding it there. We made sure there was an individualized view of the situation. We did not forcibly medicate anyone. But they had to stay until they were cured. We did not put them in a jail, we put them in a hospital. Tuberculosis is an area where isolation is sometimes mandatory. In sars, quarantines was crucial. It was one of the main things that allowed them to control the sars outbreak. Even though we didnt have a treatment. We knew that if we isolated the people that had sars and scrupulous infection control, they would not spread it to others. But before they had been diagnosed, they exposed many people. And if they werent isolated, they might have spread it to more and more generations so that we globally quarantines quite a few people. It was one of the most effective ways to stop the outbreak. It has been voluntary so far. We had two patients in the u. S. , they exposed 14 to 50 healthcare workers before they were diagnosed. Those healthcare workers were furloughed. They were said to go home, dont have contact with others in the incubation. Was 14 days incubation period was 14 days. I dont know if you want to mention anything more. The cdc is not generally thought of as a regulatory agency. We had some small powers with respect to things like this in terms of what is being imported into the United States and patients moving from state to state. There have been some not unreasoned unrecent cases. Usually, we prefer to do it in a voluntary fashion than a regulatory fashion. Other questions . I know that we learned quite a bit from the anthrax bio terrorist threat. Can you give us information about how we can handle a threat from people that would be very devastating and obviously very lethal . What about prevention of bioterrorism . I will comment that there is a Strong Network throughout the United States and we really partnered with local and state Health Departments. It starts with an astute clinician. Someone who recognizes there is something odd. Characteristic of a possible bioterrorism related pathogen. Once that decision or clinician alerts the local Health Department, they can sometimes do the Rapid Testing locally. The cdc is often involved at an early stage. One of the reasons that we do humanitarian efforts, sending staff to investigate ebola outbreaks is that there is still a lot to learn about it. In the event it is used as a bioterrorism agent, the cdc is involved in research that helps us establish whether there are vaccine candidates and all sorts of things in the hopes of better preparing us for something. I dont think ebola is the most likely agent of bioterrorism. It doesnt last very long in the environment is my understanding. The ideal agent is a little more longlived than ebola. If you want to import, play, or work with it, one of the things we can do is ensure that laboratories that worked. Can you extend on that comment that was just mentioned as it relates to various viruses that are resistant to existing antibacterial medication in how you handle that . Do you work in conjunction with pharmaceutical companies or the fda to accelerate a cure . Do you understand the question . I think there are major challenges that face us in the Infectious Disease world. Emerging infections like monkeypox or sars, resistant infections. And intentionally created infections, something the terrorist makes or unintentionally gets out of the laboratory. We really are at risk of losing antibiotics. One of the things that we have done is shine a light on it, do surveillance to track what is happening around the country and sound the alarm. Certain organisms are very concerning. And now we have implementation programs working with cms and fda and a top priority right now is to make sure that every hospital in the country has an Antimicrobial Stewardship Program to make sure antibiotics are being used correctly or excessively. Not excessively. So we want to get it right so patients have the right treatment. Building the global capacity is also very important. Lets take a few more questions. Can you hear me . Good evening. People are coming into america and coming in from south america and places unknown. What is being done by the centers of disease to protect americans because those children are being sent to relatives throughout america. What is being done to protect the rest of these people . We can take the microphone and bring it here. It is very moving. There is a federal response run by fema and is doing with a very complex legal and humanitarian project. They walk for 15 hours, coming in quite ill. Actually, vaccination rates are very high. There is one disease, chickenpox, that is not routinely vaccinated for. So what is being done when they come in . There are certainly medical needs that need to be addressed and we have been advising in a consultative fashion folks that are dealing with that fulltime. Do we have a second microphone what are the significant similarities between human and nonhuman originated disease . If you look at emerging infections by which i mean new Infectious Diseases, the majority of them, 70 have originated from animals. A lot of this sharing of pathogens, they have certain viruses that they can pass on to humans as opposed to other nonmammal animals. You look at the array of pathogens and it is really astounding. From sars, hiv, rabies, even malaria. A lot of it worked out, we looked at how humans and animals interact because of that possibility of transmission between animals and humans. I studied comparative anatomy and i look at humans as just another animal in many cases and i think the viruses and bacteria that infect many animal populations are naturally going to infect us. I presume that a disease can jump species unless proven otherwise. I am curious about implications of Climate Change on the outbreaks we are seeing in the u. S. The emergence of this species in arizona has taken us by surprise and were looking at if warmer weather might be accounting for the population numbers. And also there is data that suggests that particular ticks bite humans more readily at warmer temperatures. If Climate Change is happening, it does highlight that there can be Public Health repercussions we have not thought about. Time for a few more questions. I have heard you talk a lot about physical illness. My biggest concern, which is very evident in the multiple school shootings, 15 a year now, it is really the Mental Health of america. I am wondering how you guys are addressing that are tracing that potentially back to antidepressants or pharmaceutical companies . I think that is the biggest killer, especially with suicide in my generation. I think it is going to get worse. We start with shining a light on a problem. Right now, we are seeing a huge problem with prescription opiate abuse. And it is entirely caused by doctors. We have seen a 400 increase in the prescription of opiates. Sometimes the treatment becomes a problem. Prescription opiates kill more people than heroin and cocaine combined. I dont think we are going to find a simple solution. I think we have a need to deal with Supportive School environments. We need to deal with a whole host of things that they can do to address violence. They look at things like what are the things that work to reduce injury . Injury is the leading cause of death that includes car crashes and drug overdoses and violence. That includes car crashes and suicides. None of our programs are as wellfunded as we would like them to be. Two questions. The first is about the ebola virus. It is emerging in the middle east, almost 250. We dont know what starts at and what is the hose. The second part you shared with us is the management when it comes to the human part. What do you do with infected animals when it comes to bats or cattle . We are working closely with the government of saudi arabia to help them get a handle on the outbreak. We have learned a great deal. It is increasingly clear that the large increase in cases there was spread in a hospital. It is bad news because it shouldnt happen. It is good news because it is easy to control. We began doing studies. Where did the first cases start . There may be a camel source of this. The more we investigated, they were almost all associated with hospitals. That is the first important finding we have had. We have seen a plummeting of cases since we identified that. We have embedded staff with the saudi response. We want to identify those initial cases to understand what the source maybe. I think its important understand that the cdc is a human health agency. We dont have a lot of authority or ability to work on diseases when they are happening in animals unless they are associated with an active human outbreak. There are many effective physicians who work on animal borne diseases at cdc. The key is we recognize we live in such interconnected world at the idea of ones health becomes important. We work with our partners, with United States apartment agriculture. We work with local veterinarians. When we dont have a piece of the puzzle we tried to connect with partners who do. We try to make sure we are covering those bases. Give time for 12 more questions. There are two in the middle. I have a question. If somebody has an interest in whether the cdc is working on anything in particular, is there something on your website to ask a question to find out if you guys are doing research on a particular issue . Or is happening somewhere they are planning on visiting . You can start with the cdc website. We have apps, including the yellow book, the bible for anyone who wants to travel anywhere in the world. What to do, what to worry about. We have one 1800 cdc info. Good evening. I have a question regarding the spread of whooping cough, which has now in southern california, there are outbreaks in certain areas. Recently i had friends fly from italy to lax with a woman infected, and i would like to know what regulatory body would have input or control, or authority to isolate those people, because so many are exposed. A friend has spent a year rush to the hospital several times. When this one was coughing, she was whooping. She was sitting between them, both were infected. What can we do as citizens who happen to travel quite a bit to put pressure on those individuals or that particular authorities to control this . It seems to be getting out of hand. During bird flu when i was flying back and forth i would see a of individuals coming from china or parts of the asian continent wearing masks. Why dont we insist upon that . What role would you have in that . That is a big concern of mine. Whooping cough is resurging. We are not vaccinating enough people because people have misconceptions about vaccines and think these are things of the past. The vaccine is not as effective as we would like. It seems to wayne wane after three years. Plus, the whooping cough bacteria has evolved and seems to be invading our vaccines. Evading our vaccines. This is a question of working with the fda to come up with a better vaccine. In terms of regulatory action, certain things are appropriate. It is often the state or local government that has the authority in terms of people coming into the country. Cdc operates quarantines. But the solution is not to try to build a perfect moat around the country. Other people will be safer and we will be safer as well. I dont know if you want to say any last words. We are out of time. I think im going to sleep better than i would knowing these incredibly talented people [inaudible] [applause] thank you. I am so excited to welcome everyone here. I work with an Organization Called Global Health court. We bring new talent to the field of Global Health. We work with amazing Young Leaders to bring their voices. Which is why i love the aspen new voices fellowship read it ensures we have diverse thinkers raising voices to affect social change. Well have the opportunity to listen to Great Stories and meet 10 great innovators who will bring them to live for us. Storytelling is a powerful tool. Any great storyteller is a great teacher, which is something i knew growing up. I had a mother who was a teacher and librarian. Sometimes defined seem like it would never stop with a mother who was a librarian. But my mother knew the powers stories had to open the world